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Abstract

On May 1, 1998 the appointment of David Levine as Chief Executive Officer of the new Ottawa Hospital was announced. He began his duties on June 15 following six weeks of tumultuous public outcry led by the media and a select group of individuals discontented with his politics. As a result he was not provided the usual honeymoon and his work was under a microscope from day one. His peers, however, had little doubt. Scott Rowand, CEO of Hamilton Health Sciences Corporation is representative. He has publicly written that "Levine possesses the skills, attributes, and knowledge necessary to provide the leadership required by the Ottawa Hospital for the mammoth task set by the Health Services Restructuring Commission."

Levine came into a challenging situation. Less than a year earlier the Commission (HSRC) had directed that the Ottawa Civic, Ottawa General and Riverside Hospitals amalgamate by October 31, 1998. The new corporation would also receive most programs from the Salvation Army Grace Hospital and the French-speaking L'Hôpital Montfort. By April of the following year The Ottawa Hospital corporation was formed, the Board of Trustees was selected and it took up a planning process that was well underway. A consolidated plan for The Ottawa Hospital was presented to the new board in July 1998 and approved with these directives: proceed to Phase II; resolve outstanding issues; and investigate the use of the Riverside Campus as a potential location for ambulatory services.

Levine was a new executive at a new hospital - yet to be forged from existing components and blending academic medicine with community medicine - in a strange town with a defiant press and vocal dissidents, in a very visible community on a national stage. Worth watching.

Create the Vision

New leaders inevitably establish in their minds what an organization should feel like and focus on an organizational value that everyone can agree on. So it is not surprising that in an open and congenial conversation with Hospital Quarterly, David Levine came back several times to the importance of a "noble cause" to help gel the merged hospitals. His cause? "Excellence in patient care."

Very likely in the time leading up to his June 15 start date he had formed a personal agenda to bring the organizations together. When the plan was approved he had been officially on board for only one month but the board's directive already had his stamp on it. He will tell you that his management program is driven by the merger. "The issue of a merger adds a distinct dimension to the CEO role. A merger means that all activities are affected by different groups with different needs, and different facilities with different cultures. A CEO, new or otherwise, has to respond."

Levine provides these touchstones:

Recognize that an organization has to be driven by a noble cause. For us it is patient care.

Commit to development. A merger needs a vision. This vision cannot be tied to one or the other culture or to one or the other facility. Rather it moves on and so . . .

Acknowledge a new culture as it evolves.

Communicate. The noble cause, the vision and the emerging culture need to be seen and need to recognized.

There is evidence, says Levine, that some Canadian hospital mergers have not recognized this central focus. He cites an example of one major restructured hospital corporation where nothing has appeared to happen in two years, there is no clear vision, and an emphasis on a lot of planning will ensure that it will be four years before anything is implemented. As a result, the volume of research conducted is down, medical staff numbers are down, morale is down, and quality of care is down. According to Levine, it doesn't have to be this way. Clearly, he accepts the burden of defining what the merged organization will do without being charmed by existing cultures, existing organizations and existing facilities. He is committed to development, to strong communications, and to demonstrating that the new vision works. In this way a new organization with a new culture will emerge. You only have to watch him to see that he moves quickly and energetically.

When Levine began he found that the master plan was expensive, existing facilities would require extensive renovations, and the opportunity to participate in a developing integrated healthcare system needed to be addressed more fully. Levine saw the possibilities. A creative student of hospital administration, he was familiar with the Mayo Clinic model and the opportunity of its being central to the new vision for Ottawa. He then followed a favorite strategy of successful newly appointed CEOs: When you know what needs to be done, do it sooner rather than later. But don't rush into anything.

Levine: "We recognized an important opportunity to develop a model that includes a free-standing, and neutral ambulatory care center. This center allows rapid access to assessment, evaluation and diagnostic services and rapid turn around and referral to treatment in an appropriate setting, such as home, other community agencies, urgent-care centers, hospital ambulatory care clinics, or within a hospital; and it is open to the community, practitioners, rural hospitals, clinics, pharmacists and others who are part of the healthcare community. In effect, it becomes the gateway to an integrated healthcare delivery system. This new vision is less expensive, saves an existing site and has rallied support from the community of users and providers." The proposal was formulated, budgeted, committed to print and submitted within four months to the Health Services Restructuring Commission.
Levine knew what had to be done and he did it sooner rather than later.

Levine's zones of power typically include internal ones:

doctors and nurses

staff organizations

unions

board of directors

foundation

executives

And external ones:

municipal leaders

media

health council

volunteers

donors

other healthcare providers

other healthcare institutions

Provincial government

University

From the Dean's point of view

Dr. Peter Walker is Dean of the Faculty of Medicine at the University of Ottawa. He is buoyed by the new opportunities that the Ottawa health sciences strategy brings. According to Walker, Ottawa has always had good hospitals and a good medical faculty but not a real partnership with common challenges and opportunities. "We are developing a partnership with a merger that is going pretty well, especially in an environment which has had a lot of rivalry in its history. David has been a real catalyst in bringing this to fruition. He has an incredible amount of energy, ideas and creativity; he is receptive, a very quick study, constantly challenges us and carries through with his own commitments. And we have fun."

"The bringing together of the existing Health Sciences Center and the introduction of the Gateway or Ambulatory Center is an important opportunity for the University. The planned center's community base introduces a new richness not encountered before allowing us to change the concept of academic medicine. Students and residents now get to train in a non-tertiary center - a reflection of the real world that also provides an important window for new research efforts focused on health services. And . . . many of our grads often look back and see a 'holier than thou' organization that did not properly prepare them to become 'independent entrepreneurs.' This restructuring, however, means we can teach in conditions that reflect the real world for our students. This is exciting."

Maintain the ebb and flow

But the life of a hospital goes on and needs to be nurtured. "While we plan and restructure we also acknowledge important milestones in the making. We have, for example, a breast cancer clinic which is recognized for excellence. It is high-tech, warm, and something to be proud of. We embraced it and made it part of the merged hospital by bringing it to the gateway site. This gave it immediate visibility and recognition. Champions of similar clinics now see a vision and want to duplicate the formula, allowing the General and Civic campuses to concentrate on cost-effective inpatient services. This is new. It is a win and a demonstration of the board's commitment to effective development."

Similarly, shortly after the merger some eight new operating rooms were opened at the Civic campus. "It is important that this kind of development be recognized, credit appropriately given and commitments made to continue the growth. This creates an opportunity for the new CEO to recognize, endorse and continue individual and departmental efforts within the merged hospital." Wins like this, says Levine, do not have to be large such as a complete new operating theater; they could be as simple as the introduction of new equipment.

Report Card / Interim

Noble Cause - recognizedVision - establishedReorganization - in progress
Staffing has been rationalized at the management level through a rigorous and fair process and budgets reflect this. Heads of departments have been named and placed.

External Network - developing
Community support is solidified. Opportunities to speak are recurrent, support from the press is evident and there is a general feeling among the public that The Ottawa Hospital is operating very well. Effective relations with political and policy executives at all levels of government are in place.

Internal Network - operative
The medical heads of departments and management have an effective working relationship and there is ongoing dialogue with colleagues on both a personal and professional level. This includes the board, local hospital executives, academics and officials at other teaching hospitals.

Communications - a priority in place
The organization and the community know what the board and executive of the new hospital stand for.

Bilingualism - working policy in place
This policy has been put into the context of the hospitals mission for its community.

Find Your Champions

Levine understands the importance of finding champions within the hospital and securing their support for the new strategies. This especially means building strong ties to the medical staff and demonstrating support for their research.

Levine cites his appointment to the hospital in Verdun. He became president there at the young age of 32. At the very beginning he approached a friend and said: "I need a mentor, I need to have the ear of the hospital's key leaders. Whom do I turn to?" The advice was to turn to Dr. George Bélanger, president of the medical association of the hospital and its chief surgeon (and later head of the pension fund for physicians in Quebec). This advice led to dinner at Les Halles with seven other heads of departments. "It was like a round table. They grilled me for all my thoughts while clearly communicating their convictions and expectations to me. A memorable and significant dinner that started important long-term relationships. Here in Ottawa I took the same route almost immediately and met with the Dean of the Faculty of Medicine and every department head. Dinner was at Le Métro. Here we began discussions and our vision for the merged hospital began to take shape."

. . . and Build Your Team

But a merged hospital has other problems. Merging requires extensive staff changes throughout the organization and a certain amount of downsizing to deal with duplication. These changes need to be implemented quickly. Otherwise, says Levine, people will leave, they'll take their buyout and be gone and you'll have less say in who stays to help build the new vision. For this reason new CEOs like to act quickly to replace and name new managers who will get on board with the new program from the beginning.

At The Ottawa Hospital, Levine's first big test was the designation of a Chief of Staff. When he made the appointment, one of the local newspapers - which had been very critical - gave him high marks for selecting respected orthopedic surgeon Dr. Chris Carruthers, a unilingual anglophone. Good start.

Next, each campus was given its own structure and its own corporate operating officer, who was also a Nursing VP, a VP Professional Services and a VP Ambulatory Services. "These players have a campus role and a corporate role. This ensures that people have a leader and that they and their personal programs are not orphaned. Organizational changes go much deeper of course. Six months later we have new executives and new directors in place across the board. As a result we have a new organization and a management group reduced by 25%."

From the Chief of Staff's Point of View

Dr. Chris Carruthers has provided some insight into the complexities of the merger. Should The Ottawa Hospital, be two full-service hospitals under one administration or one full-service hospital with two campuses? The potential impacts vary. For example: the two-hospital scenario would certainly result in residents being distributed too thinly to ensure a good education; both teaching and learning would suffer. Not a good idea. Another challenge: tertiary care at both sites would stretch the resources of house staff and so compromises would have to be introduced. The hospital could try to find substitutes or find family physicians willing to come in on salary. The consensus is, however, that they would not be interested. Perhaps a mandatory service program will be required. And then there are practice plans. Would there be one plan for both sites or two separate plans? How would the workload be assigned? Would selected procedures be site-specific? The financial impact of these potential changes is unknown.

For Ottawa, these are special problems. The use of practice plans is not well developed, the hospitals were run very differently and merging two different styles and cultures is not easy. "The Restructuring Commission also introduced the merging of purely community-care facilities with those practising academic medicine - a challenge requiring all of us to be management pioneers."

Carruthers endorses the respect and loyalty exhibited by Dean Walker of the University of Ottawa and others, saying simply: "David Levine is the best man to help us meet these challenges."

Establish and Communicate a Network

Business leaders will say that a new CEO must establish strong relationships with board members. Levine goes a step further. He says: "Every CEO has to be aware of internal and external zones of power. Knowing the individuals within these zones means understanding their corporate needs and their personal needs. You need to know them as professionals and as individuals. Each zone plays a role and it is important to understand the interfaces and to leverage the opportunities these provide."

How does the CEO manage these zones? Levine:

Define the noble cause of the organization.

Identify the leaders. True champions and leaders are dedicated and committed to the noble cause.

Communicate with these champions and 'work' with them. This means: Meet with them one on one; be around, do grand rounds, maintain a presence and be visible, and in the process repeat key themes and messages:

patient focus;

the new vision and new plan;

the emerging winners of restructuring;
and, he adds;

dedication to research.

"Only by appropriately recognizing and integrating these zones of power with the organization can a CEO manage to achieve the organization's noble cause. It is significant because it helps immeasurably to identify and obtain resources for the organization and manage inevitable conflict. In this way the CEO acquires jurisdiction and authority - neither exist if they aren't recognized by those already in authority."

And finally, it's a common theme, but a good executive is a good communicator. Levine: "The big overriding thing is to communicate. It is so important to effective management that I'm going to take some personal time and write about it in the context of these zones of power." (Look for HQ to feature his views.)

BriefCase

The policy of bilingualism throughout the hospital was set before Levine arrived, but was left to him to implement. Almost all stakeholders have an interest in this issue and so the challenge provided Levine with an opportunity to shine.

Rather than impose bilingualism he obtained agreement from board and staff that its reality can only be achieved in the context of the hospital's noble cause: excellent patient care. He says this approach has worked well. In effect, the priority of bilingualism is measured in terms of its contribution to the hospital's ability to deliver its services. This has de-politicized the issue and put the policy in the proper perspective.

Lessons learned

Levine says that new CEOs have the challenge of weighing the fear of "risks taken" with the temptation of "just doing it." On the one hand, it is tempting to ask a lot of questions and work towards consensus but inevitably things won't get done; on the other, being decisive and proactive can ruffle feathers. As a result, the CEO doesn't always get it right. There were instances, he admits, where he dragged out issues and, in the end, probably should have taken more risk.

He also feels that he missed an opportunity to develop a better relationship with the district health council. As a result, council members were not as involved with the master planning process as he would have liked. This council is particularly large - reaching from Pembroke to Cornwall - and further involvement would have consumed a lot of time. Time, however, he now feels would have been well spent.

David Levine

Education

Bachelor's degree in Civil Engineering from McGill University.

Master's degree in Biomedical Engineering from Imperial College of Science and Technology, London, England.

Master's degree in Health Administration from the University of Montreal.

Career

Chief Executive Officer of the St. Louis Park Avenue Community Health Center Montreal. Began with a staff of three; ended up with a staff of 150.

Consultant to the Minister of Economic Development for the Government of Quebec

Assistant to the Vice-President and Director of Coordination and Prevention at the Commission of Occupational Health and Safety

Chief Executive Officer of the Verdun General Hospital

Chief Executive Officer of Notre-Dame Hospital in Montreal

Delegate General, Quebec Government House in New York City

Current position: President and Chief Executive Officer, The Ottawa Hospital

Service

Surveyor for the Canadian Council on Health Services Accreditation

President of the Association of Canadian Teaching Hospitals

Member of the Board and Executive Committee for the Association of Quebec Hospitals

Vice-President of the Centraide Charity campaign

President of the Association of Directors of Health and Social Services in Quebec

The Ottawa Hospital
The Ottawa Hospital resulted from the amalgamation of the Riverside Hospital, the Ottawa Civic Hospital, and the Ottawa General Hospital under one corporation. It includes selected programs from the Salvation Army Grace Hospital and L'Hopital Montfort.

1111 acute-care beds

83 acute mental-health beds for adult patients

38 regional rehabilitation beds

36 local long-term and 33 local short-term rehabilitation beds

80 sub-acute beds

bilingual services policy

A report card

Last May, when David Levine's appointment was made public and the hospital board had to deal with more than a month of protest, hue and cry from the press and determined activists, David Levine stayed in the background. "It was the board's issue and I was still in New York," he says. A few times, however, his measured responses were reported by the press. On one occasion he suggested that his critics evaluate his work in six months. Well, as of December 15 David Levine had served The Ottawa Hospital for half a year.

David Levine measures his performance by pointing to an established vision; a reorganized hospital; and a supporting network of professionals, executives, staff and community players - all helping to achieve common objectives and plans to ensure excellent patient care for the citizens of Ottawa.